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NURS 3512 acute & chronic > Week 11 ICP > Flashcards

Week 11 ICP Flashcards

1
Q

What is normal ICP?

A

<15 mm Hg

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2
Q

risk of ischemia and infarction occurs at what measurment of ICP?

A

> 20 mm Hg

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3
Q

What are the 3 components that try to compensate for increased ICP?

A
  1. brain tissue (distention of dura, compression of tissue)
  2. Blood (vasoconstriction)
  3. Cerebrospinal fluid (make less, displace down spinal column)
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4
Q

What is normal CPP?

A

70-100 mm Hg

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5
Q

What CPP is neccessary for adequate perfusion?

A

50-60 mm Hg

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6
Q

What CPP is incompatibe with life?

A

<30 mm Hg

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7
Q

how do we determine CPP?

A

MAP- ICP= CPP

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8
Q

How do we increase CPP?

A

decrease ICP
or
increase MAP

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9
Q

What is hypercarbia?

A

Increased PaCO2 causes dilation of cerebral vessels which can increase ICP

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10
Q

What is Hypocarbia?

A

Decreased PaC02 causes vasoconstriction of cerebral vessels which can decrease perfusion

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11
Q

What is Hypoxemia?

A

damages brain tissue and causes dilation of cerebral vessels which can increase ICP

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12
Q

What do nurses monitor to avoid ICP increase?

A

BP
O2
CO2

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13
Q
A
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14
Q

What do nurses want to prevent, primary or secondary brain injury?

A

secondary brain injury!

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15
Q

How do we prevent and manage increased ICP?

A
  1. HOB elevated 30* - no sudden vertical changes
  2. Keep head midline - no neck flexion to squish blood vessels
  3. no Hip flexion
  4. no coughing /straining/ constipation
  5. O2 want >95% (ambubag before & after suction)
  6. Quiet environment
  7. DO NOT cluster care d/t stress/clenching
  8. VS, mouth care, etc
  9. monitor closely BP, HR, temp, ICP, MAP, report inadequate CPP
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16
Q

What is the first sign of IICP?

A

altered LOC

17
Q

What is a late sign of IICP?

A

Cushings triad - then Cheyenne Stokes

18
Q

What are three signs of altered LOC?

A
  1. unilateral pupil change in size, equality and/or reactivity
  2. altered respiratory pattern
  3. unilateral hemiparesis (opposite side)
19
Q

What are the 3 signs of decreased LOC (stupor)?

A
  1. Unilateral or bilateral pupil changes
  2. cheyne- stokes
  3. decorticate or decerebrate posturing
20
Q

What are 3 signs of coma?

A
  1. bilaterally fixed and dilated pupils
  2. Respiratory arrest
  3. absence of motor response (flaccid)
21
Q

What do we do if there are changes that suggest an increase in ICP?

A

tell physician immediately!

22
Q

What is an early indicator of decreasing LOC?

A

restlessness & irritability

23
Q

What is cushings triad?

A
  1. BP goes up
  2. HR goes down
  3. irregular resps (cheyne stokes)
24
Q

What are 4 components of neuro assessment?

A
  1. LOC
  2. Pupils
  3. VS
  4. Limb movement/strength
25
Q

Which posture is worse, decerebrate or decorticate?

A

Decerebrate

26
Q

External Ventriculr Drain (EVD). What, When, Why, How

A

what: Catheter inserted into ventrical (ventriculostomy)

When: Usually when GCS is less than 8 (coma)

Why: Used to monitor ICP and guide clinical care

How: Can also remove cerebral spinal fluid to decrease intracranial pressure

27
Q

What are 3 considerations when using EVD?

A
  1. high risk of infection (prophylactic antibiotics and aspectic technique)
  2. Keep body position still
  3. transducer level with ear (use level)
28
Q

What drugs are used with ICP and why?

A
  1. Osmotic diuretic - Mannitol = increase MAP (blood less thick)
  2. Hypertonic Saline 3% = increase Na
  3. Loop diuretic - Lasix = adjunct to mannitol
  4. Anti-seizure meds - Dilantin (phenytoin)
  5. Barbs/sedation - propofol if ICP very high to decrease cerebral metabolism
  6. Corticosteroids - antiinflammatory for brain tumour (Decadron)
  7. Stool softeners - Colace (docusate sodium)
  8. Analgesics- fentanyl
  9. Antibiotic - broad spectrum
  10. Antipyretics - Tylenol - b/c TBI = hypermetabolic=fever
29
Q

How do we position a patient with high ICP in a coma and why?

A

side lying
prevent tongue obstructing airway

30
Q

What two things must we remember when suctioning someone with high ICP?

A
  1. Abubag before and after to replace oxygen
  2. limit suction to 2 passes <10sec
31
Q

What do we put in to relieve pressure on diaphragm for someone with high ICP?

A

Nasogastric

32
Q

What is used to maintain airway if necessary?

A

intubation
mechanical ventilation

33
Q

What are the 7 things we must do to care for patients with IICP?

A
  1. Maintain airway/resp
  2. Fluid & electrolytes balance
  3. Body positioning
  4. Nutrition therapy - needs lots of calories- hypermetabolic
  5. Supportive therapy
  6. Protect from injury
  7. Psychological care (patient & family)
34
Q

What 3 ways do we monitor fluid and electrolyte balance?

A
  1. amount accurately (I&O) - too much can increase ICP
  2. Monitor electrolytes - diuretics and IV fluid can affect them
  3. Monitor urinary output-
    -DI
    - SIADH (b/c pressure on pituitary= too much antipee hormone = increase Na)
35
Q

What is supportive therapy for ICP care?

A

Reduce metabolic demands as much as possible to prevent further increase in ICP
-Control fever to keep energy burning down ,monitor for seizures
-Manage Pain
-Decrease Stimuli

36
Q

How do we protect from injury (confusion, agitation, seizures) in ICP care?

A

-Least restraint approach b/c it stresses the fuck out of everyone and increases ICP
-Pad side rails
-Light Sedation when appropriate
-Calm reassuring approach

37
Q

How do we provide psychological care for patients and families when caring for increased ICP?

A

-Competent assured manner
-Short simple explanations
-Allow family participation in care when possible

NURS 3512 acute & chronic (29 decks)

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